• This form will help place you with the right counselor(s). As soon as you have been placed, we will call to set up the first appointment.


Client Name *
Client Name
Gender *
Marital Status *
Seeking: *
Spouse's Name (if applicable)
Spouse's Name (if applicable)
Address *
Address
Phone *
Phone
Can we leave a message? *
Are you presently seeing anyone else regarding the above issue? OR have you seen someone in the past? *
PAYMENT POLICY: CLM is a pledge-based ministry. We do not have a set fee for counseling because we do not want finances to be the reason you do not seek biblical counseling. To help you determine what you want to contribute, please consider the following information: - Pledging $120 per counseling hour would cover all expenses to run as a ministry. However, because not all clients can afford this amount we ask you to pledge an amount appropriate for you. - The amount of money you pledge goes directly to the counselor spending time with you. - Any amount contributed over $50.00 per 1-hour session is considered a tax-deductible donation. (Example: Pledge $70 and $50 will go toward the service of counseling. The remaining $20 will be reflected on a Charitable Donation Receipt mailed at the end of the year.) - Contributions may be made via cash, check, debit or credit card at the time of your counseling. - The cost of any assigned material such as books, CD’s, or online downloads will be in addition to your pledge and yours to keep. Insurance Filing: Most insurance companies do not reimburse for biblical counseling services. If your insurance company does cover this service we ask that you do your own filing. We can provide any requested information. Pledge amount per 1-hour session: (Typical pledge is $50-$75)
$

Before your first appointment:

Print and complete the Detailed Intake (for ages 16 & up) and bring to your first appointment.

OR

Print and complete the Adolescent Intake (for ages 15 & under) and bring to the first appointment.

Purpose: Used to answer initial counseling questions and provide a faster approach to understanding root issues.


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***For additional information regarding the counseling process (scheduling, confidentiality, payment) check out the FAQ’s or call us (605) 341-5305